Health equity requires transformational change: Financial incentives based on worn-out market thinking will not deliver

The Covid-19 vaccine market concentration and hoarding that left many Global South countries unable to access vaccines in a timely manner have led to calls to expand and decentralize manufacturing capacity as a critical element towards more equitable access to vaccines globally 123. Multiple initiatives are underway to build manufacturing infrastructure in low-and middle income countries (LMICs). However, without proper attention to who owns and controls the production and underlying technologies, there is a risk that well-meaning donor investments reinforce market dynamics that favour a handful of major international producers over truly local efforts 4. This is particularly relevant for the African Vaccine Manufacturing Accelerator (AVMA), the new US 1Bn financing instrument approved by the Board of Gavi, the Vaccine Alliance, in December 2023 5. Three AVMA design issues are cause of concern. First, current wording in AVMA documents defines local production as '"geographically located on the African continent" 5. Any international company that sets up a subsidiary in Africa and produces vaccines, which in newspeak is referred to as 'localized' production, is eligible for the new financing instrument. However, localized production is fundamentally different from local production in which actual ownership, management and strategic decision-making are rooted in the local (national or regional) socio-economic ecosystem and respond to local health needs, strategic objectives, and/or market opportunities. There is no reason to assume that localized production by global companies would result in more equitable outcomes than what we saw during the pandemic. Johnson & Johnson (J&J) 's production in South Africa of Covid-19 vaccines that were exported to Europe while South Africa was unable to access any vaccines is a case in point 6. To deliver health equity and security, production must be truly locally governed and as described above, embedded in national or regional health and economic development policy. Without political support and targeted financial incentives designed to address their specific needs, 7 African vaccine manufacturers will not be able to compete with established international companies that already have capabilities, knowhow and a strong financial base. Second, AVMA's financial incentives are structured to foster localization efforts by international producers, to the detriment of truly local efforts. The first financial award provided by AVMA is a milestone payment (pull incentive) upon achieving WHO Prequalification 5. This means that only companies with access to at-risk capital to finance product development and building a regulatory dossier can achieve this high bar. Established vaccine producers have the capital and can benefit from government or philanthropic grant funding for product research and development (R&D) up to registration,